Inspection Report Summary
The most recent inspection on February 24, 2025, substantiated a complaint but did not cite any deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to abuse prevention and reporting, food safety and sanitation, and life safety code compliance, including issues with involuntary seclusion, failure to timely report abuse, and fire safety concerns. Enforcement actions included an Immediate Jeopardy finding in April 2024 related to abuse and involuntary seclusion, which was later removed after corrective measures such as staff training and disciplinary actions. Complaint investigations were mostly unsubstantiated except for one substantiated complaint with no deficiencies cited and the substantiated abuse-related complaint that led to enforcement. The facility has demonstrated improvement over time, with all deficiencies from prior surveys corrected by subsequent revisit inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
3.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
26 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00253921.
Complaint Details
Complaint GA00253921 was substantiated with no deficiencies cited.
Findings
The complaint GA00253921 was substantiated with no deficiencies cited.
Report Facts
Census: 26
Inspection Report
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Carlyle Place, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 25, 2024 recertification survey.
Findings
All deficiencies cited in the August 25, 2024 recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 23, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies at Evergreen Health & Rehab.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Routine
Census: 32
Deficiencies: 4
Date: Aug 25, 2024
Visit Reason
A State Licensure survey was conducted at Carlyle Place from August 23, 2024, through August 25, 2024, to assess compliance with state health regulations.
Findings
The survey revealed deficiencies including failure to provide required Medicare Non-Coverage notices to a resident, ice build-up contamination risks in the walk-in freezer, failure to label and date opened food items, and improper wet nesting of steam table pans leading to potential bacterial growth.
Deficiencies (4)
Failed to provide the Notice of Medicare Non-Coverage (NOMNC) and incomplete Skilled Nursing Facility Advanced Notice of Non-Coverage (SNFABN) to a resident discharged from Medicare Part A services.
Ice build-up on top of food items in the walk-in freezer risking contamination.
Dietary staff failed to label and date opened food items in dry storage and refrigerators.
Wet nesting with stacks of steam table pans causing moisture and potential bacteria growth.
Report Facts
Facility census: 32
Number of residents involved in Medicare notice deficiency: 1
Dates of survey: August 23, 2024 through August 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator | Interviewed regarding failure to provide Medicare Non-Coverage notices | |
| Director of Health Services | Interviewed about facility policy and awareness of Medicare notice requirements | |
| Dining General Manager | Confirmed ice build-up and food storage issues in walk-in freezer and labeling deficiencies | |
| Healthcare Dining Manager | Confirmed ice contamination and wet nesting issues, and labeling deficiencies |
Inspection Report
Routine
Census: 32
Deficiencies: 3
Date: Aug 25, 2024
Visit Reason
A standard survey was conducted at Carlyle Place from August 23, 2024, through August 25, 2024, to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide required Medicare Non-Coverage notices, failure to ensure oxygen therapy humidification, and multiple dietary and food safety violations such as ice build-up in the walk-in freezer, unlabeled opened food items, and improper drying and storage of steam table pans.
Deficiencies (3)
Failed to provide the Notice of Medicare Non-Coverage (NOMNC) and failed to accurately complete the Skilled Nursing Facility Advanced Notice of Non-Coverage (SNFABN) for one resident discharged from Medicare Part A services.
Failed to ensure humidification was provided for one resident receiving oxygen therapy, risking medical complications.
Failed to remove ice build-up on food items in the walk-in freezer, failed to label and date opened food items, and failed to prevent wet nesting with stacks of steam table pans.
Report Facts
Facility census: 32
Residents affected: 1
Residents affected: 1
Residents receiving oxygen therapy: 6
Dates of observation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Acknowledged lack of humidifier bottle on oxygen concentrator for resident R11 |
| Director of Health Services | Stated facility lacked policy for Advanced Beneficiary Notices and was unaware resident had not received required notices | |
| Director of Nursing | DON | Stated expectations for nurses to follow oxygen administration policy and ensure humidifier bottles attached |
| Dining General Manager | DGM | Confirmed ice build-up in walk-in freezer and unlabeled food items |
| Healthcare Dining Manager | HDM | Confirmed ice build-up, unlabeled food items, and moisture in stacked steam table pans; stated dietary staff expectations |
| Minimum Data Set Coordinator | MDS Coordinator | Admitted failure to provide NOMNC form to resident R21 and incomplete SNFABN form |
Inspection Report
Life Safety
Census: 32
Capacity: 40
Deficiencies: 2
Date: Aug 24, 2024
Visit Reason
A Life Safety Code Survey was conducted at Carlyle Place Retirement Community to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, specifically failing to ensure all sprinkler heads had properly attached escutcheon plates and that fire walls were properly sealed, including a fire wall by room 342.
Deficiencies (2)
Facility failed to ensure all Escutcheon Plates were properly attached to all Sprinkler Heads.
Facility failed to ensure that all Fire Walls were properly sealed, including a fire wall by room 342.
Report Facts
Census: 32
Certified Beds: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 8/24/2024 |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 19, 2024 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 19, 2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 19, 2024 Complaint Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 28
Deficiencies: 5
Date: May 7, 2024
Visit Reason
An Abbreviated Survey was conducted on 5/6/2024 through 5/7/2024 to verify the removal of Immediate Jeopardy (IJ) related to involuntary seclusion and abuse identified during a prior survey from 4/10/2024 through 4/19/2024.
Findings
The facility failed to ensure one resident (R4) was free from involuntary seclusion and failed to report and investigate abuse allegations timely. Immediate Jeopardy was identified and later removed after corrective actions including staff training, suspension and termination of involved staff, and implementation of enhanced oversight and reporting procedures. The facility remained out of compliance at a lower scope and severity for multiple deficiencies related to abuse prevention, reporting, investigation, administration, and QAPI activities.
Deficiencies (5)
Failed to ensure resident R4 was free from involuntary seclusion by barricading the bed with a mattress and chairs for over eight hours.
Failed to report an allegation of abuse in a timely manner to the State Agency for resident R4.
Failed to investigate, correct, and prevent allegations of abuse by staff for resident R4.
Failed to effectively oversee an abuse prevention program to promote and maintain an abuse-free environment.
Failed to identify concerns and effectively implement QAPI plans related to abuse prevention system including staff to resident abuse allegations.
Report Facts
Resident census: 28
Staff trained: 43
Total staff: 51
Family questionnaires completed: 35
Resident questionnaires completed: 28
Staff interviews per week: 15
Resident rooms checked: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN QQ | Licensed Practical Nurse | Named in involuntary seclusion and abuse findings; suspended and terminated |
| RN OO | Registered Nurse | Discovered resident R4 in involuntary seclusion |
| Administrator | Informed of Immediate Jeopardy, responsible for reporting and oversight | |
| Director of Nursing | DON | Informed of Immediate Jeopardy, involved in oversight and corrective actions |
| Corporate Director of Accreditation | Provided education and oversight on abuse reporting and QAPI compliance | |
| Education Coordinator | Conducted staff training and presented findings at QAPI meetings | |
| Director of Health Services | Responsible for ongoing compliance of cited deficiencies | |
| Nursing Supervisor RN NN | Nursing Supervisor | Conducted staff interviews to ensure compliance |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 5
Date: Apr 19, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from April 10 to April 19, 2024, investigating complaint numbers GA00241710, GA00241519, and GA00236452. The visit was complaint-driven due to allegations of involuntary seclusion and failure to report and investigate abuse.
Complaint Details
The investigation was initiated due to complaints alleging involuntary seclusion and failure to report abuse. One complaint was substantiated with deficiencies cited, another was substantiated with no deficiencies, and one was unsubstantiated. Immediate Jeopardy was declared on 4/16/2024 related to the involuntary seclusion incident dated 10/27/2023.
Findings
The facility was found to have placed one resident (R4) in involuntary seclusion by barricading his bed with a mattress and chairs, restricting his movement for approximately 9 hours. The facility failed to report the abuse to the State Agency timely, did not conduct a thorough investigation, and did not implement effective corrective actions. The administration failed to oversee an abuse prevention program and did not address the incident in the QAPI committee. The Immediate Jeopardy was ongoing at the time of exit.
Deficiencies (5)
Failed to ensure one resident was free from involuntary seclusion by barricading the bed with a mattress and chairs.
Failed to report an allegation of abuse in a timely manner to the State Agency.
Failed to investigate, correct, and prevent allegations of abuse by staff for one resident.
Failed to effectively oversee an abuse prevention program to promote and maintain an abuse-free environment.
Failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related to abuse prevention.
Report Facts
Facility census: 32
Duration of involuntary seclusion: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN QQ | Licensed Practical Nurse | Named in involuntary seclusion finding for barricading resident in bed |
| RN OO | Registered Nurse | Discovered resident barricaded in bed and reported incident |
| Administrator BB | Administrator | Addressed incident internally with verbal warning, failed to report to State Agency |
| Administrator AA | Executive Director | Informed of incident, acknowledged failure to report and investigate properly |
| DON | Director of Nursing | Informed of incident, stated no facility-wide in-service or suspension occurred |
| MD | Medical Director | Not made aware of incident, expected reporting to State Agency |
| QA RN | Quality Assurance Registered Nurse | Not made aware of incident, expected reporting and corrective actions |
Inspection Report
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Carlyle Place, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
A revisit survey was conducted at Carlyle Place to verify correction of deficiencies cited during the 4/30/2023 Recertification Survey.
Findings
All deficiencies cited in the prior 4/30/2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 27
Capacity: 40
Deficiencies: 0
Date: May 5, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 30, 2023
Visit Reason
A State Licensure survey was conducted at Carlyle Place from April 28, 2023 through April 30, 2023 to assess compliance with state health regulations.
Findings
The survey identified multiple deficiencies including failure to implement stop dates for antipsychotic medications, lack of comprehensive care plans for residents with specific needs, and inadequate food safety and sanitation practices in the kitchen.
Deficiencies (3)
Failure to ensure a stop date was implemented, not to exceed 14 days, for antipsychotic medications for one resident, increasing potential for adverse consequences.
Failure to develop a comprehensive plan of care addressing suprapubic catheter care for one resident and behavioral needs for another.
Failure to ensure food items were properly dated and labeled and kitchen equipment was clean and sanitary, potentially affecting 28 residents.
Report Facts
Residents reviewed for unnecessary medications: 6
Residents reviewed for care plans: 3
Residents potentially affected by kitchen deficiencies: 28
Dates of medication orders: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding awareness of PRN psychotropic medication stop dates and hospice responsibilities. |
| AA | Registered Nurse (RN) Supervisor | Interviewed about medication renewal system and resident behavioral issues. |
| Director of Nursing (DON) | Director of Nursing | Interviewed about medication orders, care plan expectations, and documentation requirements. |
| MDS Coordinator | Confirmed lack of care plans for residents with suprapubic catheter and behavioral needs. | |
| Wendy Cross | Director of Dining | Interviewed about kitchen cleaning schedules and equipment sanitation. |
| Cook EE | Cook | Interviewed about cleaning practices of kitchen equipment. |
| Administrator | Administrator | Interviewed about kitchen staff responsibilities and cleaning expectations. |
| Dietary Manager | Dietary Manager | Interviewed about food labeling, dating, and kitchen sanitation observations. |
Inspection Report
Routine
Census: 28
Deficiencies: 5
Date: Apr 30, 2023
Visit Reason
A standard survey was conducted at Carlyle Place from April 28, 2023 through April 30, 2023 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to transmit discharge MDS assessments timely, incomplete plans of care for residents, improper storage and lack of physician orders for oxygen equipment, failure to implement stop dates for antipsychotic medications, and unsanitary kitchen conditions with unlabeled food items and unclean equipment.
Deficiencies (5)
Failure to ensure that a Discharge Minimum Data Set (MDS) assessment was transmitted within 31 days for one discharged resident.
Failure to develop a comprehensive plan of care addressing suprapubic catheter care and behavioral needs for two residents.
Failure to ensure oxygen equipment was properly stored and current physician orders were present for oxygen administration for three residents.
Failure to implement stop dates not to exceed 14 days for antipsychotic medications for one resident, increasing risk of adverse consequences.
Failure to ensure food items were properly dated and labeled and kitchen equipment was clean and sanitary, potentially affecting 28 residents.
Report Facts
Resident census: 28
Number of residents reviewed for discharge MDS: 3
Residents with oxygen equipment issues: 3
Residents reviewed for unnecessary medications: 6
Residents affected by kitchen sanitation deficiencies: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant | Provided information on respiratory tubing handling and storage |
| BB | Licensed Practical Nurse | Discussed respiratory equipment cleaning and storage responsibilities |
| CC | Licensed Practical Nurse | Discussed awareness of PRN psychotropic medication policies |
| AA | RN Supervisor | Provided information on PRN psychotropic medication renewal process |
| Wendy Cross | Director of Dining | Described kitchen equipment cleaning schedules and expectations |
| EE | Cook | Described cleaning practices for kitchen ovens |
| Administrator | Discussed kitchen staff responsibilities and expectations for cleanliness | |
| Director of Nursing | DON | Provided multiple interviews regarding care plans, medication orders, and respiratory equipment policies |
| MDS Coordinator | Confirmed missing discharge MDS transmission and care plan deficiencies |
Inspection Report
Original Licensing
Census: 28
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
A licensure survey was conducted at Carlyle Place from January 4, 2022 through January 6, 2022 to assess compliance with licensing requirements.
Findings
The standard survey revealed that the facility was in substantial compliance.
Inspection Report
Routine
Census: 28
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
A standard survey was conducted at Carlyle Place from January 4, 2022 through January 6, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 28
Capacity: 40
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00211884.
Complaint Details
Complaint #GA00211884 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint was unsubstantiated and no regulatory violations were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 4, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00207496.
Complaint Details
Complaint #GA00207496 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Routine
Census: 26
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 13, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00197836 and GA00199118.
Complaint Details
The investigation of complaints GA00197836 and GA00199118 concluded with the complaints being unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Life Safety
Census: 33
Capacity: 40
Deficiencies: 0
Date: Jul 1, 2019
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness plan requirements and Life Safety Code standards during the survey.
Inspection Report
Routine
Census: 32
Deficiencies: 0
Date: Jun 27, 2019
Visit Reason
A standard survey was conducted at Carlyle Place from June 24, 2019 through June 27, 2019 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Routine
Census: 31
Deficiencies: 0
Date: May 3, 2018
Visit Reason
A standard survey was conducted at Carlyle Place from April 30, 2018 through May 3, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B, with some deficiencies related to the standard survey.
Report Facts
Resident Census: 31
Inspection Report
Life Safety
Census: 32
Capacity: 40
Deficiencies: 0
Date: May 1, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
A follow-up to the Recertification survey of August 13, 2017 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 27, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 28, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 32
Capacity: 40
Deficiencies: 1
Date: Aug 11, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code.
Findings
The facility was found not in substantial compliance due to failure to test and maintain the fire sprinkler system, specifically the backflow preventer valves, which could place all 32 residents at risk in the event of a fire.
Deficiencies (1)
Failure to test and maintain the fire sprinkler system in accordance with NFPA 25, specifically failure to test the backflow preventer valves.
Report Facts
Census: 32
Certified Beds: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed the finding regarding failure to test backflow preventer valves |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 11, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA 00174606 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00174606 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey at Carlyle Place.
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